Lab 4 - COPD, Asthma Flashcards by David Sisa Gangai

Asthma - Diagnosis

History: previous measurements; compare values with values expected for the pt (age, gender, ethnicity, height)
Lung function tests:
- Spirometry (reduced FEV1, FEV1/FVC ratio, PEF)
- Bronchodilator reversibility test (increase in FEV1 by more or equal 200 ml/12% 15 min after inhalation of albuterol/salbutamol 400mcg)
- PEF: twice daily
- Flow volume loops (reduced peak flow and max expiration flow)
- Whole body plethysymography (increased airway resistance and total lung capacity and residual V)
Airway hyperresponsiveness:
- exposure to bronchoconstrictors (histamine), calculate provocative conc that reduces FEV1 by 20%
- exercise testing (post-exercise bronchoconstriction)
Hematalogic: total serum IgE, CBC (peripheral eosinophilia)
Imaging:
- CXR usually normal, but may show hyperinflated lungs in severe pts, pnemothorax in acute exacerbations, pneumonia in bronchopulmonary aspergillosis
- CT: bronchiectasis in severe asthma
- Skin prick test: positive in allergic asthma
- Fractional exhaled NO: eosinophilic airway inflammation
- Sputum eosinophilia –> airway inflammation

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Asthma - Differential diagnosis

Upper airway obstruction by a tumor or laryngeal edema (confirmed with flow volume loops (reduced inspiratory and expiratory flow and bronchoscopy which shows upper airway narrowing)
Endobronchial obstruction with a foreign body (persistent wheezing in a specific area of chest)
LV failure: wheezing of asthma, but presence of basilar crackles
Vocal cord dysfunction
Eosinophilic pneumonia and systemic vasculitis (Churg-Strauss syndrome), polyarteritis nodosa –> wheezing

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Salbutamol - dose and route

0,1 mg/dose (1-2) doses in aerosol (nebulizer, metered-dose inhaler with a spacer)

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Salbutamol - MoA

SABA, b2 adrenergic agonist, inhibits mast cell mediator release

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Salbutamol - Adverse effects

Tremor, peripheral vasodilation, tachycardia, palpitations. hypokalemia (increased uptake by skeletal muscle cells)

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Salbutamol - Contraindication

Thyrotoxicosis, HTN, CHD

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Salbutamol - Interactions

Increased risk of hypokalemia with glucocorticoids, diuretics and hypoxia

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Salmeterol - dose and route

50 mcg/dose (2 doses) in aerosol

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Ipratropium - dose and route

30 mcg/dose (1-2 doses) 3-4 ganger daglig, in aerosol

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Ipratropium - MoA

SAMA, muscarine receptor antagonists, prevent cholinergic nerve-induced bronchoconstriction and mucus secretion. Used in acute severe asthma following B2 agonists

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Ipratropium - Adverse effects

Dry eyes, dry mouth, cycloplegia, constipation, urinary retention

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Ipratropium - Contraindication

closed angle glaucoma, BPH

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Theophylline - Dose and route

5-6 mg/kg IV

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Theophylline - When used, MoA and adverse effects

Severe asthma if other drugs doesn't work
Both bronchodilator (inh PDE, increase cAMP) and anti-inflammatory effects
Adverse effects: nausea, vomiting, headache, anxiety, dizziness

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Fluticasone - dose and route

125 mcg, twice daily in aerosol

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Fluticasone - MoA

ICS, reduces eosinophils in the airway and sputum, and nr of activated T lymphocytes and surface mast cells in airway mucosa.

Fluticasone - Adverse effects

Oropharyngeal candidiasis, dysphonia, sore/irritated throat, toothache

Fluticasone - Contraindications

In high doses: Adverse effects of systemic corticosteroids may occur

Fluticasone - Interactions

CYP3A4 inh (cimetidine, fluconazole, verapamil) –> systemic effects in therapeutic doses

Prednisolone - dose and route

30 mg/day PO for 5-10 days

Prednisolone - Adverse effects

Cushing syndrome, osteoporosis, growth retardation, DM, PUD, HTN

Prednisolone - Contraindications

Psychosis, PUD, heart disease, HTN, DM, osteoporosis

Montelukast - dose and route

10 mg/d PO

Montelukast - MoA

Leukotriene inhibitor. Inhibits bronchoconstriction.

Montelukast - Adverse effects

Hypersensitivity, Churg Strauss syndrome, liver injury

Montelukast - Interactions

Inh CYP enzymes --> increases levels of phenytoin, warfarin, lovastatin

Asthma - Treatment

SABA --> ICS --> LABA --> high dose ICS + Leukotriene inh --> OCS

Asthma exacerbation - Treatment

O2 (achieve saturation >90%) --> SABA and OCS or IV (Methylprenisolone 40 mg IV) --> new b2 agonist + Ipratropium --> Theophylline --> intubation, mechanical ventilation (noninvasive positive pressure ventilation)

COPD - Diagnosis

Physical exam: cough sputum, exertional dyspnea, Hoovers sign, Hyperinflation (barrel chest), tripod position (to facilitate actions of sternocleidomastoid, scalene, and intercostal muscles), pink puffers vs blue bloaters Lung function test: - Post- bronchodilator spirometry: 0,4 mg salbutamol. Reduced FEV1 and FEV1/FVC --> reduced below 0,7. Increased total lung capacity, FRC and RV - Reduced diffusing capacity for carbon monoxide (lung parenchymal destruction) ABG and oximetry: hypoxemia, PCO2 and pH Increased hematocrit: chronic hypoxemia Imaging: - CXR: hyperinflation (increased lung V, flattened diaphragm), emphysema (bullae), pulmonary HTN - CT: emphysema, coexisting interstitial lung diseases, bronchiectasis, lung cancer alpha1AT def testing CBC: asses for erythrocytosis (can occurs secondary to hypoxemia), anemia (worsen dyspnea) ECG/Echo: exclude CHF, identify cor pulmonale in pst with chronic hypoxia

COPD- Treatment

Nicotine replacement therapy A: SABA or SAMA B: LABA or LAMA --> persistent symptoms: Both C: LAMA --> Further exacerbations: LABA + LAMA or LABA + ICS D: LAMA + LABA or LABA + ICS --> further exacerbations: LABA + LABA + ICS --> further exacerbations: Roflumilast If continued symptoms, try theophylline or oral corticosteroids

COPD- nonpharm therapy

Influenza vaccine (pneumococcal, Bodetella pertussis) Pulmonary rehabilitation Lung volume reduction surgery Lung transplantation

COPD- Differential diagnosis

CHF, PE, chronic asthma, pulmonary fibrosis

Tiotropium - Dose and route

18 mcg 1 dose/day capsule for inhalation (inhalationpowder)